Patient History Form - Free Download
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Patient History Form
Medical History Form 3
Medical History Form
Medications: All prescription, non-prescription, vitamins, home remedies, or herbal medication
Name
Dose (ex: mg/pill)
How often Date medication started
Social History
YES NO
Marital Status: single married divorced widowed other
Spouse / Partner Name:
Who lives at home with you
Do you have an end of life directive (Living will, medical power of attorney, etc.)
Tobacco Use: (type & amount per day)
Date quit
Seat Belt Use: always ___ occasionally ___ never ___
Are you, a relative, close friend, or companion who will be involved in your visit deaf or hard of hearing
Current Family Health Status
Member Date of Birth Deceased Cause of Death
Father
Brother(s)
Sister(s)
Children
1.
Statement of Present Health:
Current Disease(s)
Health Status (good,
fair or poor)
Last, First, Middle
Primary Physician
Today's Date D.O.B. & Age
Employer Job Title
Excellent Good
Male Female
Fair
Poor
Medication Allergies
Alcohol Use: (type &frequency)
Is alcohol a concern for you or others
Caffeine Intake:
None: Coffee/Tea
Cups/Day
Cups/Day
Soda
Diet: (please rate)
Good: Fair: Poor:
Mother
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